Joint Action on HIV and co-infection prevention and harm reduction HA-REACT Principles and challenges of HA-REACT as an example of multilateral and multisectoral programme Mika Salminen, Ph. D, Research Professor Outi Karvonen, Project Manager 19 September 2017, St. Petersburg
HIV diagnoses acquired through injecting drug use, 2014, EU/EEA Rate per 100 000 population < 1 1 to <3 3 to <5 > 5 Not included or not reporting Non-visible countries Liechtenstein Luxembourg Malta Source: ECDC/WHO (2015). HIV/AIDS Surveillance in Europe, 2014
1240 new HIV diagnoses among PWID in 2015 5-10 cases in Denmark, Norway, Finland <5 cases in Czech Republic, Slovakia, Croatia, Hungary, Cyprus, Netherlands, Slovenia, Iceland Source: ECDC/WHO (Nov 2016) Source: PRELIMINARY DATA ECDC/WHO (SoS2016)
TB among people who use drugs No statistical data easily available; WHO Global database: 13 from 31 EU/EEA countries reported 450 intravenous drug users (2%) among approx. 28 500 TB cases in the respective countries in 2016; Link: drug use HIV infection co-infection HIV/TB; Experiences and guidance prepared by the TUBIDU project used in the HA-REACT Joint Action. Empowering the public health system and civil society to fight the tuberculosis epidemic among vulnerable groups. Desk review; Handbook for community based organisations on tuberculosis services for people who inject drugs; Training outline for trainings based on TUBIDU Handbook
TB among people who use drugs
9 Seven key recommended interventions COMBINE THESE KEY INTERVENTIONS TO ENHANCE PREVENTION SYNERGY AND EFFECTIVENESS INJECTION EQUIPMENT: Provision of and legal access to clean drug injection equipment, including sufficient supply of sterile needles and syringes, free of charge, as part of a combined multicomponent approach, implemented through harmreduction, counselling and treatment programmes VACCINATION: hepatitis A and B, tetanus, influenza vaccines, and, in particular for HIV-positive individuals, pneumococcal vaccine DRUG DEPENDENCE TREATMENT: Opioid substitution treatment and other effective forms of drug treatment TESTING: Voluntary diagnostic testing with informed consent for HIV, HCV, (HBV for unvaccinated) and other infections including TB should be routinely offered and linked to referral to treatment INFECTIOUS DISEASE TREATMENT: Antiviral treatment based on clinical indications for those who are HIV, HBV or HCV-infected. Antituberculosis treatment for active TB cases. TB prophylactic therapy should be considered for latent TB cases. HEALTH PROMOTION: health promotion focused on safer injecting behaviour; sexual health including condom use; and disease prevention, testing and treatment TARGETED DELIVERY OF SERVICES: Services should be combined and organised and delivered according to user needs and local conditions; this includes the provision of services through fixed sites offering drug treatment, harm reduction, counselling and testing, and referrals to general primary health and specialist medical services.
Basic facts The HA-REACT Joint action is based on: Communication from the Commission [COM(2009)569] on Combating HIV/AIDS in the European Union and neighbouring countries, 2009-2013 Commission [SWD(2014)106] Action plan on HIV/AIDS in the EU and neighbouring countries 2014-2016
Basic facts (2) HA-REACT Budget: approx. 3,75 million EUR co-funding by EC 80% Duration: October 2015 September 2018 Coordination: National Institute for Health and Welfare (THL), Finland Partners: 22 partners from 18 countries
Geographical coverage of HA-REACT
HIV trend HIV case reports and prevalence (15% weight; no increase in case reports or prevalence=0; increase in one=1; increase in both=2; high without an increase=1) Focusing the action: use of ECDC and EMCDDA objective selection criteria Table 1: Indicators of HIV trend, transmission risk and prevention coverage AT BE BG HR CY CZ DK EE FI FR DE EL HU IS IE IT LV LT LU MT NL NO PL PT RO SK SI ES SE UK 0 0 2 0 0 0 0 1 0 0 0 1 0 0 0 0 2 1 0 0 0 0 0 0 2 0 0 0 0 0 0 0 2 0 1 2 0 2 2 2 0 0 0 2 0 0 0 0 Transmission risk prevalence of injecting drug use, changes in injecting risk behaviour (HCV prevalence and trends) (10% weight; no changes=0; moderate increase in one criteria=1; increase in >1 criteria=2) OST coverage % estimated problem opiate user population receiving OST (cut-off 30%) (25% weight; OST coverage >30%=0; no data=1; OST coverage <30%=2) 0 1 1 0 0 0 1 1 1 0 0 0 2 1 0 0 2 2 0 0 0 0 2 1 1 2 0 0 1 0 NSP coverage Number of syringes given out per PWID per year (cut-off 100 syringes) (25% weight; NSP coverage >100=0; no data=1; NSP coverage<100=2) 1 2 1 0 2 0 1 0 0 1 1 2 2 1 1 1 2 1 0 1 1 0 1 1 2 2 1 0 1 1 Taking part in the Joint Action x x x x x x x x x x x x x x x x x x x x Scores (maximum 2) 0, 3 0,8 1 0 0, 6 0 0, 5 0,6 0, 3 0, 3 0, 3 0,9 1,2 0, 5 Ranking of those participating in the JA (1=greatest need/opportunity to improve harm reduction situation) 6 3 8 5 2 1 4 6 NO ALERT no evidence for increase in case reports or HIV/HCV prevalence and/or transmission risk and/or low intervention coverage 0, 3 0, 3 1,5 0, 9 0 0, 3 0, 3 0 0,8 0,5 1, 3 CONCERN - Subnational increase in HIV/HCV prevalence and/or transmission risk or consistent but non-significant rise at national level. ALERT evidence for significant increase in case reports or HIV/HCV prevalence and/or increase in transmission risk and/or low intervention coverage. Information unknown/not reported to EMCDDA/ECDC. 1 0, 3 0 0, 5 0, 3 Mika Salminen/Outi Karvonen 9
Planning of the HA-REACT Joint Action Background concept paper from the European Commission (commented by the EU HIV/AIDS Think Tank) Support from NDPHS Expert Group on HIV, TB and Associated Infections Logical Framework Approach as a planning tool Based on the analysis of problems and development needs of the beneficiaries Participatory approach listening to professionals from Focus countries: Latvia, Lithuania and Hungary (both government organisations and NGOs) Aiming at sustainability To bring added value to the whole EU, not only Focus countries
Planning meetings Logical Framework Approach workshops during spring 2016: WP4 Testing and linkage to care, Budapest, 15-16 February WP8 Sustainability and long-term funding, Riga, 14-15 March WP5 Scaling up harm reduction, Vilnius, 16-17 March WP6 Harm reduction and continuity of care in prisons, Prague, 18-19 April WP7 Integrated care, Tallinn, 25-26 April
Objectives of HA-REACT Zero new HIV cases, reduced HCV and TB among PWID in the EU by 2020 Improved prevention and treatment of blood-borne infections and TB in priority regions and priority groups in the European Union Purpose Improved capacity to respond to HIV and co-infection risks and provide harm reduction with specific focus on people who inject drugs (PWID) in the EU Direct beneficiaries: professionals working with PWID Ultimate beneficiaries: people who inject drugs
Zero new HIV, reduced HCV and TB among PWID in the EU by 2020 Improved prevention and treatment of blood-borne infections and TB in priority regions and priority groups in the European Union Improved capacity to respond to HIV and co-infection risks and provide harm reduction with specific focus on people who inject drugs (PWID) in EU 0. Management Work Package 4 Work Package 5 Work Package 6 Work Package 7 Work Package 8 0. Admin and management of the Joint Action 1. Improved early diagnosis of HIV, viral hepatitis and TB, as well as improve d linkage to care for PWID 2. Harm reduction scaled up in EU based on Latvian and Lithuanian cases 3. Increased harm reduction and improved continuity of care for PWID in prison settings 4. Improved provision of integrated HIV, HCV, TB treatment and harm reduction for PWID 5. National programmes updated to overcome barriers to respond to HIV, TB and HCV-related needs of PWID in the EU, specifically in the focus countries Structure and objectives of the Joint Action
HA-REACT Work Packages and their leadership WP1. Coordination THL, Finland WP2. Dissemination CHIP, Denmark WP3. Evaluation UKE ZIS, Hamburg WP4. Testing and linkage to care DAH, Berlin WP5. Scaling up harm reduction CIBER (ISCIII), Spain WP6. Harm reduction and continuity of care in prisons ISFF, Frankfurt WP7. Integrated care NIHD, Estonia WP8 Sustainability and long-term funding CHIP, Denmark
Advisory Board CHAFEA DG SANTE DG HOME ECDC EMCDDA WHO/EURO Civil Society Forum on Drugs /Correlation network Civil Society Forum on HIV/AIDS European network of people who use drugs (EuroNPUD) Eurasian Harm Reduction Network (EHRN) European Association for the Study of the Liver (EASL) European Liver Patients Association (ELPA) NDPHS Expert Group on HIV, TB and Associated Infections UNODC European Forum for Primary Care (EFPC)
Activities so far 1st Steering Committee in Luxembourg, 8-9 December 2015 Kick-off in Vilnius, 14 January 2016 2 Advisory Board meetings (Vilnius and Riga) 5 Steering Committee meetings Partnership Forum in Riga, November 2016 CHAFEA Symposium in Malta, January 2017
WP4 objectives Testing and linkage to care Improved early diagnosis of HIV, viral hepatitis and TB, as well as improved linkage to care for PWID 1.Personnel working with PWID in Hungary and Latvia trained in low-threshold testing of HIV, HCV 2.An interactive training manual and e-learning package on HIV and HCV testing in low threshold settings for personnel who work with people who use drugs, with special focus on women and peers, developed. 3.Awareness of clients of their infection status, of prevention and treatment of HIV, HCV and TB, improved. 4. Access to treatment after positive test result is ensured. 5. Gender-specific approach in testing services focused on women who use drugs developed and implemented.
WP4 activities so far WP4 Testing and linkage to care Improved early diagnosis of HIV, viral hepatitis and TB, as well as improved linkage to care for PWID Training on HIV/HCV testing November 15-17, 2016, Latvia December 13-15, 2016, Hungary May 23-25, 2917, Latvia Leaflets and posters developed to encourage PWID to take rapid HIV and HCV tests (Lv, Hu, Eng, Ru) Training manual and e-learning tool started.
Leaflets and posters to promote HIV/HCV tests
WP5 objectives Harm reduction Harm reduction scaled up in EU based on Latvian and Lithuanian cases 1.PWID epidemiology and harm reduction interventions assessed in Latvia and Lithuania 2.Training package to care providers and policy makers on HR interventions developed and implemented 3. Harm reduction interventions implemented in Latvia and Lithuania
WP5 activities so far Country mission implemented: Regular meetings in Focus Countries (January, February, April and June) and by skype to determine general situation in the countries, main barriers and necessities. Jan 2015
WP5 activities so far (2) WP5 Scaling up harm reduction Harm reduction scaled up in EU based on Latvian and Lithuanian cases Seminars for Debate in Vilnius and Riga, April 2016 - Analysis of : - successful experiences in other countries - legal framework for the scale-up of HR: fully developed. - Political will toward harm reduction, - drug policy and HIV/AIDS - Role of private sector: - need to be involved (Lt) Study visits for participants from Latvia (October 2016) and Lithuania (September 2017), to Madrid and Barcelona Study visit to Prague, 25-27 April, 2017
WP5 activities so far (3) WP5 Scaling up harm reduction Mobile unit as a low-threshold service for drug users started in January 2017 in Riga Nurse, outreach worker, social worker 23 hours per week Needle and syringe exchange -Testing on HIV, hep B, hep C, and syphilis - Condoms - TB consulting -Social and peer counselling
WP6 objectives Prison settings Increased harm reduction and improved continuity of care for PWID in prison settings 1.Situation analysis / mapping of needed support in the participating countries implemented 2.Medical, social and other prison professionals trained to work with PWID and to provide harm reduction services (incl. OST, NSP, condom provision and psychological support) 3. IEC materials developed for PWID and staff in prisons 4. Practical toolkit for harm reduction in prisons made available 5. Condom provision and other harm reduction measures piloted in one prison 6. Policy brief developed based on experiences from the component
WP6 activities so far WP6 Prison settings Increased harm reduction and improved continuity of care for PWID in prison settings E-learning modules developed for prison http://harmreduction.eu/ Study tour for prison staff from Czech Republic to Berlin (October 6-7, 2016) Pilot prison chosen in Prague and distribution of condoms started; International seminar on harm reduction in prisons, Warsaw, March, 2017 80 participants
WP6 activities so far (3) WP6 Prison settings Needle exchange and other harm reduction measures in prison settings workshop in Luxembourg, 29-30 June, 2017 Approx. 60 participants from 14 countries Visit to Schrassig prison
WP7 objectives Integrated care Improved provision of integrated HIV, HCV, TB treatment and harm reduction for PWID 1.Capacity of health, social and civil society professionals in providing better quality of care for PWID improved 2.Evidence- and practice- based tools and instructional materials developed and provided for implementation of better quality care for PWID
WP7 activities so far WP7 Integrated care Improved provision of integrated HIV, HCV, TB treatment and harm reduction for people who inject drugs International workshop on building a platform for integrated care, 5 April, 2017, Vilnius (Lithuania) overview of different approaches to integrating care for people who inject drugs and highlight how these necessitate new roles, responsibilities, skills and competencies (Lithuania, United Kingdom) overview of good practices of integrated care from the countries already implementing effective solutions (Spain, Portugal, Germany, United Kingdom (including Scotland) reflections on patients experiences, needs and expectations and how to involve patients and community in developing services for PWID (Estonia, Portugal) Mapping report of existing guidelines on quality of care and different models of care under preparation.
WP8 objectives Sustainability and long-term funding National programmes updated to overcome barriers to respond to HIV, TB and HCV-related needs of PWID in the EU, specifically in the focus countries (WP8) 1.Strategies for national AIDS programmes for planning resource mobilisation, allocation and financial sustainability for activities addressing HIV-related needs of PWID suggested 2.Strategies for removing provider-dependant barriers in access to highquality HIV, co-infection and harm reduction services to PWID mapped, analysed and proposed 3.Strategies for removing customer-dependant barriers in access to highquality HIV, co-infection and harm reduction services to PWID mapped, analysed and proposed 4. Strategies for removing structural barriers in access to high-quality HIV, hepatitis and TB services to PWID mapped, analysed and proposed
WP8 activities so far WP8 Sustainability and long-term funding National programmes updated to overcome barriers to respond to HIV, TB and HCV-related needs of PWID in the EU, specifically in the focus countries HA-REACT Sustainable Funding meeting in October 26, 2016, Budapest (Hungary) Meeting on financing and sustainability of harm reduction services on 6 April, 2017, Vilnius (Lithuania) Literature review, policy review and survey under preparation Guidance on funding mechanisms drafted.
Next activities National workshops on models of care to be organized in Lithuania (7 September), Czech Republic (16 October) and Estonia (30 August), Hungary (to be confirmed); Training workshop on harm reduction interventions, Lithuania (October); Training on TB, gender-specific approach in testing and harm reduction interventions for NGOs in December 2017 (Budapest, to be confirmed) Harm reduction for people who inject drugs in Europe: findings from three major European projects session at the Addictions Conference in Lisbon, 25 th October Partnership Forum on 26-27 October in Lisbon Advisory Board on the 26 th Steering Committee on the 26 th Training of trainers workshop on harm reduction in prisons, Poland (November).
Challenges 22 partner organisations; 18 countries different languages and cultures; Different attitudes towards harm reduction and people who inject drugs; Political changes; Merging of two partners into the Ministry of Human Capacities in Hungary; Problems with rapid HIV and HCV testing in low-threshold settings in Lithuania new legal acts; Bureaucracy of the EU grant system; Inevitable amendments to the grant agreement; Guidance of partners who have not earlier participated in large EU projects; Division of tasks, keeping timelines; Coordinating with other projects and programmes; Ensuring sustainability.
HA-REACT blog series Featured on the BioMed Central On Health blog and the Hepatology, Medicine and Policy (HMAP) blog Structured as interviews with Jeffrey Lazarus as WP2 lead & SC member Focuses on individual WPs Spotlights partners & their work Promotes HA-REACT Ongoing (8 published todate)
More information available: http://www.hareact.eu/en #HAREACT Project Manager Outi Karvonen, outi.karvonen@thl.fi WP2 Dissemination and WP8 lead Jeffrey Lazarus, jeffrey.lazarus@regionh.dk
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